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INTRODUCTION
Gray hair (white hair) develops naturally or prematurely in the process of human aging as a result of progressive and eventual total loss of melanocytes in the hair follicle1. All people have gray scalp hair as they grow old. It is reported that over 50% of the population experiences gray scalp hair by their late fifties. Kim et al.2 reported that 54.4% of Koreans have gray hair in their early forties.
For beauty and to look younger, people with gray hair tend to periodically dye their hair. There are over 60 kinds of hair coloring products in Korea. Despite that use of hair dye has been implicated in a variety of side effects, there has been no survey about the awareness, knowledge, and behavior of hair dye use.
Therefore, we conducted a survey to lay the foundation for understanding, preventing and treating the side effects from hair coloring products. We want to increase awareness and change the thinking of the people using hair dye.
MATERIALS AND METHODS
Subjects
A questionnaire survey was conducted for adult males and females aged over 20 and who had gray hair regardless of the use of hair coloring products for about 12 months, from November 2009 until October 2010. The survey subjects were patients and the patients' guardians who had visited the dermatology clinic at St. Paul's Hospital, College of Medicine, The Catholic University of Korea and people who belong to churches, senior citizens' community centers and nonprofit organizations in the immediate area of the St. Paul's Hospital. A total of 521 people participated in the questionnaire survey. Among the 521 people who participated in survey questionnaire, the responses of 21 people were excluded from analysis because they did not complete over 50% of the items. The responses of 500 survey subjects were used for analysis.
Methods
The questionnaire was composed of 26 questions and list of 68 kinds of hair coloring products on the Korean market. The questionnaire asked for basic information including gender and age, clinical findings of gray hair and the related information, use or non-use of hair coloring products and the status of use, hair dyeing-related side effects and recognition of side effects (Table 1). Some question items were designed so that the survey subjects could make multiple choices.
RESULTS
Demographic and medical description
Medical history report included 116 people reporting systemic disease, in which 37 people (7.4%) with hypertension and 21 (4.2%) with diabetes mellitus. A total of 48 people responded that they had previous skin disease; 9 (1.8%) had atopic dermatitis, 7 (1.4%) had skin allergy, and 6 (1.2%) had tinea.
Clinical findings of gray hair
The highest proportion of subjects reported 40~49 years of age (194 people, 38.8%) as age of onset of gray hair, followed by 50~59 years of age (112 people, 22.4%), 30~39 years of age (103 people, 20.6%), over 60 years of age (54 people, 10.8%), 20~29 years of age (25 people, 5.0%), and 10~19 years of age (12 people, 2.4%) (Table 2). Two hundred thirty four people (46.8%) indicated that they had experienced stress due to their gray hair. Independent sample t-tests demonstrated the older the subjects were, the greater the stress level reported because of gray hair (p<0.01), and a higher proportion of females reported stress (p<0.05). According to the results of the distribution of gray hair, the number of cases of focal distribution (320 people, 64%) was greater than the number of cases of diffuse distribution (180 people, 36.0%). However, no statistical difference in age was shown for the distribution of gray hair. For site of focal distribution of gray hair, the frontal area and temporal area showed the high distribution (Table 3).
Use of hair coloring products
Three hundred nineteen people (63.8%) had experience with dyeing their hair. Principle reasons were "to look younger" (169 people, 53%) and "to maintain a good impression" (117 people, 36.7%) replied 'to maintain a good impression' (Fig. 1). Most subjects started dyeing after 40 years of age (Table 2), usually monthly. On the brand of hair dye, the majority of the subjects (233 people, 73.0%) did not reply accurately even when an appendix with more than 60 types of hair dye was provided.
Hair dyeing related side effects and recognition of side effects
Side effects were reported by 76 subjects (23.8%). Most reported pruritus (69 people, 90.8%), a sensation of eye tingling (36 people, 47.4%), and erythema (24 people, 31.6%) (Table 4). From the 76 respondents who experienced side effects, 20 people (26.3%) visited a medical provider for treatment.
For the reasons for not visiting a medical provider, most people (25 people, 44.6%) answered that the side effects were not severe and 22 people (39.3%) regarded side effects as a normal part of hair dyeing (Table 5). Despite the side effects, a large portion of the survey subjects (68 out of 76 people, 89.5%) continue to dye their hair (Fig. 2), and most of them (36 out of 68 people, 53%) said it was because the side effect was bearable. Sixteen out of 68 people (23.5%) said they did not like gray hair even though the side effect was severe. Fourteen out of 68 people (20.6%) think severe side effects are bearable if they use dye only occasionally, and 2 out of 68 people (2.9%) said that they kept dyeing their hair because it's the best way to hide their gray hair. Fifty five people (72.4%) changed hair dye products due to side effects, and of them, 47.3% (26 out of 55 people) experienced side effects even after they changed the product, most often pruritus (26 people, 100%) (Table 4). For the question on whether they would continue with the hair dye, 256 people (80.2%) gave a positive answer.
In the analysis of the differences of knowing which hair dyeing product they were using between the two groups who experienced side effects and did not experience side effects, the percentage of knowing the exact hair dyeing brand name was higher in the group with side effects (39.5% vs. 23.0%), but this did not differ statistically.
DISCUSSION
Graying of the scalp hair is an inevitable physiologic process in human aging. It is caused by the loss of the pigmented-forming melanocytes from the hair follicles, which reflects loss of the melanocyte stem cell population in the aging hair follicles1,3,4.
We surveyed clinical findings of gray hair. Forty to 49 years of age was the most frequent onset age of gray hair (194 out of 500 people). In the focal distribution of gray hair, the frontal area and temporal area revealed the high distribution. However, as this result was a personal report rather than the objective assessment, it suggests that the site of focal distribution that was visible to the subjects was the most commonly reported.
In current culture, the desire to look younger and the interest in beauty are widespread. Hair color has an important role in this. Many people do not want graying hair and they seek hair dyeing products to cover it. This is supported by our survey responses that most subjects said they dye their hair to look younger. Numerous hair dye products are being produced and sold according to such social needs. However, even though 68 types of commercially available hair dye products were arranged for them to choose in this survey, large number of the people who had experience with hair dye (233 out of 319 people, 73.0%) did not know which hair dye product they were using. Even if they experienced side effects due to hair dyeing, many people did not know exact brand name. The results reflect that many people did not have great interest about the type of hair dye used.
Hair dyeing products can cause various adverse effects, including allergic contact dermatitis5,6. Additionally, an association with cancer and other systemic disease has also been suggested7-14. Among the composition of hair dye, para-phenylenediamine, m-aminophenol, p-methylaminophenol and prophylenglycol are known as the primary substances15 that cause allergic contact dermatitis, but it is not easy to determine the other substances that cause side effects as many different types of products contain various additives such as henna or squid ink color16-21. In most previous studies, the prevalence of the side effects due to hair dye has been obtained through patch testing with para-phenylenediamine. However, the prevalence of positive patch test result is not equivalent to prevalence of hair dye allergy22. The prevalence of the side effects from hair dye has not been established in Korean people. In this study, the prevalence of the side effects due to hair dye is 23.8% (76 out of 319 people). The result that 47.2% (26 out of 55) people experienced side effects even after they changed the product suggests that the mild symptoms induced by hair dyeing, such as a tingling sensation of the eye and pruritus, may be under-recognized. Despite the experience of side effects, most (68 of 76 people, 89.5%) continue hair dyeing. Furthermore, a small portion of the subjects (20 out of 76 people) who experienced side effects visited the hospital for treatment. People do not realize typically the seriousness of the side effects or the need for treatment. Also, even if the patients recognize the side effects, they considering them normal symptoms that can appear with dyeing rather than recognizing them as adverse effects, and these are results in the people continuing to dye their hair because there are no other alternatives.
In this study, many people did not know the exact brand name of the hair dye product that they were using, and continued hair dyeing in spite of side effects. Also, a large portion of the people who experienced side effects of hair dyeing did not receive any treatment. The results suggest that most of the people who had experienced hair dyeing have insufficient knowledge of hair dye products. This study was conducted to determine the public's perception on hair dye products and the side effects, and as a result, it was confirmed that the level of awareness was fairly low.
Therefore, it is necessary for people to fully know the ingredients of hair coloring products and to properly use them, such as conducting a patch test for the causative agents of contact dermatitis before use, in order to decrease the side effect caused by hair coloring products. Directions and included literature of hair dye products must be improved to inform people about the ingredients, the side effects and patch test method. It is advisable to introduce a system that will enables users to become aware of the ingredients of hair coloring products and the side effects of hair coloring products. We should give broad opportunities for users to become aware of the side effects of hair coloring through education, publicity and publication of an informational booklet so that people can appropriately use hair coloring products. Additionally, for the people who experience side effects of hair dye products, a patch test for the main substances that cause contact dermatitis may be helpful to select hair dye products and to decrease the side effects of them.
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